Angiographic embolization for hemorrhage following pelvic fracture

Tesoriero, Ronald; Bruns, Brandon R.; Narayan, Mayur; DuBose, Joseph J.; Guliani, Sundeep; Brenner, Megan; Boswell, Sharon; Stein, Deborah M.; Scalea, Thomas M.

doi:10.1097/ta.0000000000001259

Cited by 125 publications

(106 citation statements)

References 42 publications

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“…Our time to PPP in the current study, 44 minutes, is within the framework of these international publications. When compared to the time to angiography of 286 minutes (18) and 193–301 minutes (19) reported in the two most recent AE series, PPP is faster.…”

Section: Discussionmentioning

confidence: 86%

“…An alternate comparison is to a modern day series of pelvic fracture patients undergoing angiography (18). Indications for angiography in this study included contrast blush on CT scan (32%), pelvic hematoma (30%), and hemodynamic instability defined as a SBP < 90 mmHg (33%).…”

Section: Discussionmentioning

confidence: 99%

“…The mean transfusion was 4 units of RBCs in the ED and the patients remained hypotensive. The “trigger” for angiography at other institutions includes a pelvic hematoma, a blush on CT scan in a stable patient, a SBP < 90mmHg regardless of transfusion requirements, or for the first unit of RBCs transfused (18). A similar statement could be made of patients undergoing AE; perhaps they didn’t need the intervention and simply would have stopped bleeding.…”

Section: Discussionmentioning

confidence: 99%

“…This, however, is not currently a reality in many trauma centers. Additionally, time to arterial hemorrhage control using AE, even in the most advanced level I trauma centers with hybrid facilities requires 3–5 hours to accomplish, particularly on nights and weekends (18,19). …”

Section: Introductionmentioning

confidence: 99%

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Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures

Burlew

Moore

Stahel

et al. 2017

Journal of Trauma and Acute Care Surgery

147

146

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Background A 2015 AAST trial reported a 32% mortality for pelvic fracture patients in shock. Angioembolization (AE) is the most common intervention; the Maryland group revealed time to AE averaged 5 hours. The goal of this study was to evaluate the time to intervention and outcomes of an alternative approach for pelvic hemorrhage. We hypothesized preperitoneal pelvic packing (PPP) results in a shorter time to intervention and lower mortality. Methods In 2004 we initiated a PPP protocol for pelvic fracture hemorrhage. Results During the 11-year study, 2293 patients were admitted with pelvic fractures; 128 (6%) patients underwent PPP (mean age 44 ± 2 years and ISS 48 ± 1.2). The lowest emergency department SBP was 74 mmHg and highest heart rate was 120. Median time to operation was 44 minutes and 3 additional operations were performed in 109 (85%) patients. Median RBC transfusions prior to SICU admission compared to the 24 postoperative hours were 8 versus 3 units (p<0.05). After PPP, 16 (13%) patients underwent AE with a documented arterial blush. Mortality in this high-risk group was 21%. Death was due to brain injury (9), multiple organ failure (4), pulmonary or cardiac failure (6), withdrawal of support (4), adverse physiology (3), and Mucor infection (1). Of those patients with physiologic exhaustion, 2 died in the OR at 89 and 100 minutes after arrival while 1 died 9 hours after arrival. Conclusions PPP results in a shorter time to intervention and lower mortality compared to modern series utilizing AE. Examining mortality, only 3 (2%) deaths were attributed to the immediate sequelae of bleeding with physiologic failure. With time to death under 100 minutes in 2 patients, AE is unlikely to have been feasible. PPP should be employed for pelvic fracture related bleeding in the patient who remains unstable despite initial transfusion.

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Section: Discussionmentioning

confidence: 86%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures

Burlew

Moore

Stahel

et al. 2017

Journal of Trauma and Acute Care Surgery

147

146

View full text Add to dashboard Cite

show abstract

“…Earlier intervention by trauma surgeons with techniques, such as preperitoneal packing, aortic balloon occlusion, and use of hybrid operative suites, may improve survival outcomes (2).…”

Section: Discussionmentioning

confidence: 99%

Surgical Management and Angioembolization in a Hybrid Operating Room for a Patient with a Pelvic Bone Fracture and Other Lethal Injuries

Jung

Bae

2017

Trauma Image Proced

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A 14-year-old female patient with no medical history was admitted via the emergency room with blunt trauma. At admission, she was in shock status and had a positive focused abdominal sonography for trauma (FAST) sign with a right acetabulum wall fracture, superior and inferior ramus fractures, and an open book type fracture of the pelvis (Fig. 1). In addition, she had a hemoperitoneum and peritonitis due to bowel perforation and a mesenteric injury. We planned to perform an emergency operation in a hybrid operating room with angioembolization at the same time. First, segmental resection of the jejunum was done and then angioembolization of internal iliac artery branch was performed (Fig. 2., 3.) The current management of pelvic fracture patients with other lethal injuries who are hemodynamically unstable consists of aggressive resuscitation, emergency operation, and angioembolization. Despite this multidisciplinary approach, a high mortality rate was seen in these high-risk patients with pelvic bone fracture and other lethal injuries. Therefore, we pursued proper therapies to improve patient outcomes. We have experienced successful treatment for patients with pelvic bone plus other lethal injuries.(Trauma Image Proced 2017(1):27-28)

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